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Reoperative coronary artery bypass via left thoracotomy
1Department of Cardiovascular Surgery, Kyorin Medical School, Tokyo, Japan.
Insights
This study details a novel surgical approach for coronary artery bypass grafting reoperation in a patient with complex triple-vessel disease. The technique utilized a patent internal thoracic artery and left thoracotomy for safe and effective bypass grafting.
Area of Science:
- Cardiovascular Surgery
- Cardiac Reoperation
- Coronary Artery Disease Management
Background:
- A 49-year-old female patient with a history of prior coronary artery bypass grafting (CABG) presented with recurrent effort angina.
- Coronary angiography revealed progression to triple-vessel disease, including occlusion of the saphenous vein graft and a jeopardized right coronary artery.
Observation:
- The patient's left internal thoracic artery (LITA) remained patent, while the saphenous vein graft (SVG) had occluded.
- A decision was made for surgical revascularization due to the extent of disease and graft failure.
Findings:
- A left thoracotomy approach was successfully employed, leveraging the patent LITA.
- New bypass grafts were created using the right radial artery to the left circumflex artery and the right gastroepiploic artery to the right coronary artery (4th marginal branch).
- Postoperative angiography confirmed the patency of all newly constructed bypass grafts.
Implications:
- This case highlights the utility of left thoracotomy for CABG reoperation when a LITA remains patent.
- The described technique offers a viable option for complex revascularization, particularly in patients with failed prior SVG grafts.
- This approach may improve outcomes for patients requiring repeat cardiac surgery.
Abstract:
The patient was a 49-year-old woman. When she was 39 years old, she underwent coronary artery bypass grafting (left internal thoracic artery to left anterior descending artery, saphenous vein graft to first diagonal branch). At the age 48, she had effort angina. On coronary angiography, triple-vessel disease was found, and she was treated conservatively. Progression of the disease was confirmed with detection of the left circumflex artery associated with jeopardized collateral to the right coronary artery showing total occlusion. The patient underwent reoperation. Since the left internal thoracic artery was patent despite occlusion of the saphenous vein graft, the approach of left thoracotomy was employed. Under cardiopulmonary bypass with ventricular fibrillation and left vent through left atrial appendage, the right radial artery was anastomosed to the left circumflex artery from the descending thoracic aorta, and the right gastroepiploic artery was anastomosed to the right coronary artery (4AV branch). Patency of the bypass was confirmed postoperatively. We consider this operative technique was especially useful for reoperation in cases of a patent internal thoracic artery in which left thoracotomy can be conducted safely.